Provider Demographics
NPI:1932102746
Name:GOTTHELF, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GOTTHELF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E JOHNSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6091
Mailing Address - Country:US
Mailing Address - Phone:850-477-3252
Mailing Address - Fax:850-477-2659
Practice Address - Street 1:2120 E JOHNSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6091
Practice Address - Country:US
Practice Address - Phone:850-477-3252
Practice Address - Fax:850-477-2659
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592319848OtherTAX ID # (FEIN)
FLK0730Medicare ID - Type UnspecifiedGROUP #
FL592319848OtherTAX ID # (FEIN)
FL17449YMedicare ID - Type UnspecifiedINDIVIDUAL #